Transforming Hospice Care: The Evolving Role of Medical Directors

How have federal regulatory changes reshaped the role of hospice medical directors from mere formalities to key players in patient care and organizational leadership? Join Jennifer Kennedy and our esteemed guest, Dr. Daniel Maison, as we unpack the historical "three S's" and explore the significant transformations driven by CMS regulations. You'll gain valuable insights into the evolving responsibilities of hospice medical directors, highlighting their integral contributions to both operational and clinical aspects within hospice organizations.

Tune in to discover practical strategies for engaging medical directors in leadership roles and optimizing interdisciplinary group (IDG) meetings. Dr. Maison shares his expert advice on creating a collaborative environment that values physicians' contributions, prevents burnout, and fosters continuous education. Learn how to leverage physicians' expertise for educational opportunities and involve them in decision-making processes to enhance patient care and drive organizational growth. This episode promises a comprehensive look at the enhanced recognition and vital role of hospice medical directors in today's healthcare landscape.

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Transcript

Evolution of Hospice Medical Directors

Speaker 1 0:00

Greetings. I'm Jennifer Kennedy, the lead for Compliance and Quality at CHAP, and welcome to another special edition of CHAPcast. In this series, we harness the knowledge and experience of our board of directors to help you jumpstart insightful and meaningful discussions in your own organization. The goal of these special podcasts is to equip your organization with greater insight and guidance that you need to excel and push the boundaries of quality in a positive direction.

Speaker 1 0:49

Our guest, our board member, a friend of mine, dr Daniel Maison, about what's been happening over the years with the hospice medical director. There has been a lot of change related to the hospice medical director and the role that he or she occupies over, I would say, the last decade plus, and that was really related to many federal regulatory changes. So the role of that position has always been a clinician, a member of the interdisciplinary team and a participant in the organizational leadership and a participant in the organizational leadership. But I think that really hasn't been the case for many years and in speaking with Dan today, we're going to look at that and talk about the ever-evolving role of that hospice medical director, thank you. So, without further ado, I'd like to introduce Dr Maison.

Speaker 1 2:14

He's been practicing hospice and palliative medicine for over 25 years and he's working as a full-time hospice and palliative care medicine physician since 2001. He's currently a regional medical director for Accent Care and he is board certified in both internal medicine and hospice and palliative medicine. Dan speaks at national meetings and state meetings. He's worked extensively at the local, regional, state and national levels and he is currently the vice chair on the board of directors for CHAP. In 2006, dan was elected a fellow of the American Academy of Hospice and Palliative Medicine and in 2013, he was nominated by the AHPM as a visionary in the field of hospice and palliative care. Welcome to CHAPcast, dan. It's so great to have you here.

Speaker 2 3:19

Thanks so much, Jennifer. Always a treat to get to speak with you.

Speaker 1 3:22

I know we're going to be talking about a really interesting topic today. You've been a longtime doc in hospice and palliative care and you've been there when all of these federal regulations have been changing. Federal regulations have been changing and you know, I think it's because of that. It's changed the role, the flavor of the hospice medical director in a hospice and I wanted to. My first question to you is how do you think that role of the physician in hospice has changed?

Speaker 2 4:04

Yeah well, thank you for the question. You know, really, when you think, when I first started out, way back in 1998, it's been true even since, before all of the really major changes that happened with the conditions of participation in and around 2008, that the physician has always been a required, important member of the interdisciplinary team. But how that played out was quite variable from hospice to hospice and for many folks there was we talked about the three S's of being a hospice medical director or hospice doctor, which was basically please show up on time, please sign and please do it pleasantly with a smile. So show up, sign and smile. We were not engaged very much in and around any sort of operational issues, oftentimes barely even engaged clinically, other than to provide feedback during the team meeting and, obviously, being present in the team meetings.

Speaker 2 5:04

But what we've seen over time and this was happening even before the regulations changed and in many ways those of us who've been doing it for a while really saw the change in regulation as an acknowledgement that we truly appreciated that there was a potentially bigger and more comprehensive role for the physician to play as a member of the team, recognizing that one of the not-so-secret weapons of hospice care in the United States is that interdisciplinary team and being recognized as part of that and being sort of, in a sense, not mandated but certain things were mandated, but really calling out that really important role not mandated but certain things were mandated, but really calling out that really important role. We really appreciate it because we were very excited to be seen as active members within the organization's, active members within the team, and being able then to really provide a level of care, involvement and engagement that those of us who fell in love with this field were really excited to get to do.

Speaker 1 6:08

So CMS really was the instigator of, you know, pushing that role out from under the leaves, if you will. Because you know, dan, when I think about the last time that I was two feet in a hospice, it was just that we relied on the physician to sign orders. And when I elevated to a leadership position inside a hospice, the medical director wasn't really the mindset of the leadership didn't change. It was okay, the doc is just part of the IDG, signs the orders and that's it to implement. I think CMS had the right idea with shining a light on the hospice medical director and hospice physicians to say, hey, hospices, you need to be more cognizant about what their role is, not only with patients and families but within the organization.

Speaker 2 7:22

I couldn't agree with you more. I really agree, and as I think, about some of the analogies. What's interesting is that, even before those changes, what you saw was in and around, exactly to your point, a hospice medical director's involvement either in really taking a very active role in patient care, operational issues, issues in and around outreach and sharing what we do and all those other parts of what being a hospice is. We were absolutely. It really varied quite a bit from organization to organization With the change in regulations. It really codified it and really, as you said, kind of got us out from under the leaves.

Speaker 2 8:06

I love that expression. That being said, much as it was the case before the new COPs, some organizations thought, okay, well, I will follow the letter of the law, I will make sure we're crossing every teen doting line, absolutely following our regulatory requirements. But it really did require a pretty big shift in culture. Some hospices seemed to have embraced it wholeheartedly. Some hospices were already doing what was asked of the new regulation, so for them it was just a validation of what they were already doing, and then for others it was, as you said, kind of quite challenging because it was a very different model than many hospices that worked under Heavens at that point, for some of them for 25 or more years.

Speaker 1 8:51

Dan, do you see any difference between utilization of your hospice doc in the medical director position, between them being part-time or full-time?

Speaker 2 9:05

Absolutely.

Speaker 2 9:06

When you think about any job that we do, if your entire job, your entire body of work, is one thing, it's going to be different than if you're sharing your time with several different obligations.

Speaker 2 9:23

That being said, when we think about people who are doing this work part-time and oftentimes that is how it is Many, many hospices in fact I don't have exact statistics, but I am sure the vast majority of physicians who are participating in interdisciplinary teams and working for hospice organizations, it is a part-time obligation as part of other things they do within their career.

Engaging Hospice Medical Directors for Leadership

Speaker 2 9:51

That is not at all meant to be an excuse or a reason why they can't be further engaged. It just means, just like anything else, if you've got multiple tasks and multiple obligations, you need to make sure you're being very intentional about how you spend your time and anything that you commit to do, that you commit to do with a level of engagement, energy, excitement and caring, as you do other things as well. So, inherent in terms of the number of hours in the day part-time versus full-time there's a difference. That being said, there's nothing about having a physician being part-time that can preclude them from being truly engaged and truly being an active and helpful member of the disciplinary team and also being of support to the organizations for which they work.

Speaker 1 10:39

Absolutely, and you mentioned the word engage. So what's the best ways to engage medical directors out there for hospice leadership, hospice IDG? You've been around a long time. What is your advice for that particular item?

Speaker 2 11:03

That's a great question. I think one of the best ways to do it is the same way we engage any other person that we are either working for, working with or supporting in a leadership position. We want to make sure that they recognize and understand how much we value them, that we value their input, that we value their contributions and that their participation really matters. And if we treat them with trust, treat them with respect and help them understand how important they are to not only the care of the patients that are under their care as part of the team, but also to the organization as a whole, that will then not only help them understand and recognize how important their participation and engagement is, but it will also reinforce to everybody else around them within the organization of the organization's view and understanding of what their role is as well too. It becomes a wonderful sort of self-propelling cycle, much like when we went.

Speaker 2 12:08

If anybody's ever attended an IDG as I'm sure almost everybody on this podcast has you'll notice sometimes that as we are trying to bring together all kinds of different folks with wonderful, super, super helpful, really incredible expert opinions and expertise and wisdom in and around the care of a patient, we have to be very intentional, that everybody on the team is meant to really be there and be there in person, but also really feels that they are an active, important part of the team. The same thing happens, blown up beyond just the IDG or an organizational level that we need to. I mean just to be really direct. If we want our physicians to be part of the leadership team in partnership with the other leaders at the organization, we need to recognize them as leaders, celebrate them as leaders and put them in a position where they not only are able to lead but also held accountable to it, but also then the entire organization understands and recognizes that leadership position, leadership structure of a hospice organization.

Speaker 1 13:25

How can you make organizational changes that directly impact the care of patients? How could you not include your hospice medical director in those decisions? Right, that makes no sense to me, but I know a lot of providers don't include their doc in those types of decisions.

Speaker 2 13:49

Yeah, and I agree and I think that, even if it's a matter of sometimes they don't, or sometimes they may under-leverage them as well too and this is not at all to say for a second that it should be always physician-led, or it has to be the doctor this, the doctor that, but you're absolutely right. Or it has to be the doctor this, the doctor that, but you're absolutely right I will still see, despite the fact that the regulatory kind of sense and structure for hospice is absolutely elevated, what physicians are expected to do within the entire hospice organization, that that engagement and leveraging, as they're thinking about new initiatives, coming up with some sort of clinical program, looking or expanding into potentially a new area with a new disease state right or a new group of providers, whatever it is. I couldn't agree with you more that there still is, anecdotally and speaking with folks around the country, variability in terms of that engagement and leveraging of the physician as part of the team and part of the organization.

Speaker 1 14:51

Do you think what we're talking about underutilization in the area of educating the team, particularly the clinical members of the team? Do you think that's an underutilization?

Speaker 2 15:04

I really do.

Speaker 2 15:05

I think that what's I think, one of the times at least when I I have the privilege of still attending IDG meetings on a regular basis, and one of the things that I love most is how much I learn from my teammates and likewise, how much I get to share with them as we all learn together.

Speaker 2 15:26

And I think, as you look at your team structure and as you look at how your IDGs go, much as physician involvement, there are certain regulatory minimums that we have to hit in terms of involvement, be able to demonstrate that involvement.

Speaker 2 15:40

So, too, with IDGs, there are certain things that we have to do to meet the regulatory minimums, but there are many things we can do beyond those to really take the IDG from being a compliant meeting to being an optimal meeting. And I think if, as you're thinking about the IDG meetings at your organizations, the point is to get there, get everything done, get everything signed and get people back out in the field again, as opposed to recognizing the incredible opportunity of having all of these dedicated, incredible professionals in one room, all focusing on the care of one patient and their chosen family, it's incredible how much expertise often years or decades of care experience in that room and I think many times we don't leverage each other enough to learn from each other, and the physician is one of those people that often, I would say, is under leveraged in terms of being somebody who could help teach and elevate the whole team.

Speaker 1 16:44

Yeah, I agree. I think there's always five minutes for the teaching moment, you know based on what's happening that day.

Speaker 2 16:51

Yeah, I will share one quick anecdote I'll never forget when I was in this is way before my hospice time, not way before, I guess a few years before back in medical school that a very wise mentor of mine said every single patient you meet has something to teach you, or maybe a lot of things, but there's something to learn from every single person that you're asked to look after, and I would say that's absolutely true on hospice as well.

Speaker 2 17:20

Every patient that we're asked to take care of, along with their chosen families, has something to teach us, whether it's a reminder about how certain diseases tend to play out, prognosis, medication management, psychosocial issues that tend to happen in general with it, or just a particular family dynamic. Whatever it is, whether it's a physician-related issue and or from some other member of the team, there's so much learning that we have every time we get together at the team meetings that, exactly to your point, it's not about giving a two-hour lecture about X, y and Z. There are teachable moments with almost every patient that we talk about that are just literally a few seconds to a minute or two, and so much wisdom and expertise can be shared on the fly as we discuss these patients at every meeting.

Speaker 1 18:11

I don't know. It sounds like you have a book in you, Dan. I'm not sure it could be.

Speaker 2 18:16

All right.

Speaker 1 18:17

Let's say I'm going to make the commitment to better engage my hospice medical director, and if I have other hospice physicians, what do you think the challenges or barriers could be to a provider who is just, you know, starting to flip this house, if you will?

Physician Engagement and Leadership Strategies

Speaker 2 18:39

That's a great, great question. This is especially true if and I had experience like this before, as I'm sure many people listening have where an organization has now decided to either add additional physician support and or now look at the physicians on their staff and decide, hey, how can we best engage them, include them, have them be leveraged, that expertise in terms of all the things we're working on and, as you can imagine, in any given organization there's not one or two things they're working on. They're often working on 10, 12, 20, 30 different things, whether they're QAPI projects, whether they're marketing initiatives, whether you're looking at engaging with and growing in a certain area with a certain disease state, whatever it is, there are tons of opportunities as a leadership team thinks about, how can I best leverage the physicians I have working with me now, how can I best engage them and partner with them, or how can I actually add them to things they weren't necessarily involved with before? And so what I would ask for, and what I found to be most helpful in the times that I've been asked to participate in things like this, is for there to be a really clear ask, and because there are so many things that any of us could help with a lot. It's really important for the leadership who's supporting the physician to have a clear sense of triage of what are the one, two, maybe three things that they really want the physician to focus on to be of most help. I'd recommend doing that and, of course, we talked previously about the part-time versus full-time.

Speaker 2 20:21

Be really realistic. If you're asking somebody to participate in something that will take 10, 15 hours a week or even five hours a week, and you know their commitment to you, which they honor very consistently, but they only have so many hours per week, make sure you know what you want from them. Have that triage to one, two, three things. Be realistic about what you're asking of them so that they don't overcommit and then let you down because, even though they want to their heart's in the right place, they don't have the time. So be realistic about that. But really then focus in on the things you really want them to really look at and be a part of. And the other challenge sometimes is bring them in, have a cup of coffee and ask them and say, hey, you've been with us now for six months to a year. Team loves you. This is great, thank you.

Speaker 2 21:20

As you're looking around the organization and things that we are absolutely rocking. We need to celebrate things that are going okay and things that need TLC. What are the two to three things you think you could be most helpful with, or what would get you the most excited, the most engaged to help with? Because, just like anybody else, all of us docs have got different things that we love more than others. We have certain things that we tend to have more ease with and we're comfortable with, have more experience with, and things that we're less excited to do.

Speaker 2 21:53

Not that it's again try to run. If the work needs to get done, needs to get done. But, as you're looking for things, if there's a choice of five things that need a physician's help and you see two of them are really a good match for the physician, you're engaging. Think about that as well. Or, if you're not sure, it's always great. In addition, in terms of building on that engagement piece, tell us, doctor, what do you think you could be most helpful. Do you feel like you're being engaged? Do you really think you're being involved at a level that's most helpful? How do you see your role being best of support to patients and family care and to the organization, and so I think that's a really good place to start.

Speaker 1 22:37

Yeah, I think that's a great place to start, and someone who's just kind of new to this, this flipped thinking what do you think they should want to learn about and where would they find resources for that?

Speaker 2 22:49

That's a really great question. So what I would do again is ask, ask your team, ask your team, engage folks saying, hey, we've got this great doc who's been working for us for a while. How do you think this person could be helping us do certain things? Ask the physician themselves, but make sure it's bad.

Speaker 2 23:13

Absolutely right yeah, and make sure that whatever you ask is going to be realistic, exactly right, and then also hold up a mirror, right? I think I've met I have friends out there and you know I'm sure we've all met people like this too, where you will have a physician, for example. They're saying we wish they were more of a leader within the organization. They took a stronger, more engaged role in terms of helping, in partnership with their colleagues, to help really set the tone of the organization you know in a really positive way in terms of high quality. You know clinical excellence and other things as well, too. Make sure that, as you're looking at yourselves, are you, as leaders in your organizations, recognizing and celebrating the doctors for the leaders that you wish they were or you wish they were more of? Make sure that you're actually calling that out in a way that's very supportive and absolutely right to your point about being balanced, One of the things that will often sometimes happen and this is absolutely human nature if your organization has been waiting to have a wonderful, engaged doctor with the time to actually help you move the needle on a bunch of things. Make sure, as you're looking at it, that you are realistic about the time it's going to take, realistic about how much time per week it's going to actually have to happen. So how long it's going to take to move the needle, how long what the commitment really is and make sure that we're managing the expectations of ourselves and of staff, because it's really easy.

Speaker 2 24:49

You know, the analogy we talk about.

Speaker 2 24:51

Right is if you, if you're, if you're dying of thirst right, and somebody gives you a cup of water, that's fantastic and you'll live.

Speaker 2 24:58

But the thing, sudden, you say, wow, can you get us water for everything?

Speaker 2 25:02

Meaning that when you have somebody who comes to you, if it's been a while, or you've added somebody new you're excited about, be sure that you are cognizant and very intentional about the fact that you don't overwhelm them with 20 things that you need fixed yesterday, especially if they've been needing a little TLC for a while, so that, as you manage expectations that the new person or the person who's newly been asked to engage at a different level, has the time and the runway and really has the ability to commit to that, to be a successful partner in those things, because, just like any other change that's coming about, if this is a significant change for your organization you're going to really want to make sure that you can log some wins early on to help people recognize and understand why you've asked your physician or physicians to be engaged in a different way or in a new way, or physicians to be engaged in a different way or in a new way, but also it will help reinforce your efforts in setting them up to success and, in doing so, be a really good long-term partner to help support your organization.

Speaker 1 26:11

Gosh, I loved everything that you just said. I mean, it's the way it's got to be in this hospital landscape for sure. It's a tough landscape right now and we need everybody. We need to harness everybody's potential and knowledge and talent in order to walk the compliance high road and give good quality care to patients and families.

Speaker 2 26:31

Hear, hear, and I would also say I mean, you guys are listening to this podcast now. If you're not sure how best to use your physician, or looking for ideas, that may be to think about, how to either think about new ways or rethink ways in which your physicians are currently engaged at your organizations.

Speaker 1 26:51

Thanks, dan. That's a great pointer and I wanted to thank you for coming on the Tapcast today. I always learn something when I talk to you over the years since I've known you, so you've given us some great knowledge today and it's really practical knowledge and applicable knowledge, so thank you so much for sharing it.

Speaker 2 27:12

Well, thank you for your incredibly kind words and absolutely mutual, jennifer. At the time, we really really appreciated getting to know you, getting to work with you Now chat has. At the time, we really really appreciate it getting to know you getting to work with you now. Chap has been absolutely fantastic and I appreciate the opportunity to talk about something that's clearly very near and dear to my heart. I really appreciate this time together.

Speaker 1 27:28

Absolutely, and thanks to all of you for taking time out of your day to plug into our special podcast From me and the entire CHAP staff. Keep your quality needle moving forward, stay safe and well, and thanks for all you do. Thank you.